Keys For Effective Treatment of Anxiety: Interoceptive Exposure and Safety Behaviors

Jill Levitt, PhD, presents Keys For Effective Treatment of Anxiety: Interoceptive Exposure and Safety Behaviors, a free 1-hour webinar. 

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Jill: I'm excited to teach what is, I think, my very favourite topic to talk about and also to work with patients on, which is treating anxiety disorders. So, the presentation title is Keys for Effective Treatment of Anxiety, which focuses specifically on interoceptive exposure and safety behaviours. Of course, we could probably extend this to a full-day workshop. So, I will cover what I can in one hour and probably jabber because I have so much to share with you. I'll very briefly touch on who we are at Feeling Good Institute. So, our mission is to alleviate suffering by elevating the practice of therapy. Our institute was started by a group of us who have been mentored by David Burns at Stanford University. 

We train and certify therapists in the processes of evidence-based CBT that are known to be most effective. Things like the use of measurement, empathy skills, increasing motivation, reducing resistance, and then, of course, the really powerful cognitive and behavioural methods that most people think of when they think of CBT. The therapists at the Feeling Good Institute are highly skilled and vetted. We all engage in a weekly system of continuous improvement, practising, role-playing, and using deliberate practice to really try and up our game kind of week after week. We have flexible services at Feeling Good Institute to meet clients' needs. So both one-hour, once-a-week, sort of traditional psychotherapy, as well as more intensive therapy. Therapy is where people come into town from out of town or work with us virtually for many hours a day, many days a week, in order to get better or faster. 
Briefly, I'll just mention how you can get your CE credit today. You'll need to complete the mandatory CE survey that Mike is going to drop in the chat box at the end of the hour. So you need to be present. You need to complete that CE survey right when the workshop ends today. And then I'll say loudly and clearly that you will not get your CE certificate immediately. We have to process the attendance. So, you will get your CE certificate via email in a week. And even though I'll say that now and I'll say it again later, I'll still get 100 emails asking where your CE certificate is. So wait a week, and it will be in your inbox. So, the plan for today is that I'll spend about half an hour covering what interoceptive exposure is. 

It's a kind of exposure that a lot of people are not familiar with, and yet one that I use all the time with the majority of my patients who have anxiety disorders. So we'll spend about half an hour on that. I'm actually going to do a demonstration with you all. We're going to actually try interoceptive exposure together, all of you if you opt-in. We'll also talk about safety behaviours for about 10 minutes, and then we'll have just a little bit of time for questions at the end. So, let's talk a little bit about anxiety and the fear of sensations that are commonly a part of most anxiety disorders. So, people often think about panic disorder for sure as involving a kind of fear of fear. 
But in my experience, clinically, most of the anxiety disorders or most people who have anxiety disorders have at least a little bit of this kind of fear of bodily sensations. And you can imagine it's problematic if you're anxious and you have a fear of bodily sensations or fear of kind of those anxious sensations because most of the time when you feel anxiety, you experience changes in your body. Right. Anxiety is kind of naturally leads to anxiety. Heart racing or trembling or sweating. And so if you're sensitive and afraid of those sensations, then you end up in this sort of feedback loop, right, where fear or anxiety or even worry leads to bodily sensations, which are then misinterpreted as dangerous or scary. And that leads to more fear, which leads to more sensations, which leads to more fear and more sensations. 

And you see kind of an automatic escalation. And so, If it's true then that so many anxiety disorders have at least part of the problem is this sort of fear of sensations, then wouldn't it be great to actually directly address the fear of sensations when we're working with people who struggle with anxiety disorders? So again, this might be very obvious to you when you treat patients with panic disorder that so clearly what's going on is sensations and then a fear of those sensations. People are clearly afraid that they're going to die, lose control, or pass out. But actually, I think if you think about your cases and your practice, if you treat patients with social anxiety, many of them are really worried that their racing heart is going to be obvious to their audience or that their hands shaking is going to cause a problem. 

Their flushing is going to be really embarrassing, or they feel frightened by the existence of those sensations. We see that oftentimes, with OCD and PTSD, fear of flying. Many patients, I'm working with someone right now who says she has a fear of flying, but when you ask what she's afraid of, she's not actually afraid that the plane's going to crash. She's afraid that she's going to have a panic attack on a plane and then something catastrophic is going to happen. And so then, clearly, she could really benefit from working on her fear of the physical sensations. I also want to show you how that can be a problem or not. As an example, whenever I public speak, including now, I always feel anxious. 

And when I feel anxious, my heart's beating fast. My hands are kind of clammy and shaky. If I were holding a piece of paper, it would kind of be like this right now. But I don't really care that that happens. It doesn't scare. It's just part of presenting, right? I just expect every time I present, I'm going to be a little bit wired, and I'm going to have some of these sensations, but they don't scare me. They don't even really bother me. And so because they don't scare me, it's not a problem for me, right? I have some fear and some anxiety, but I'm not bothered by the symptoms. On the other hand, if I were really focused on, oh my gosh, my heart's racing, and I'm going to lose control, and I'm not going to be able to speak, and this is going to happen, and that's what happened, then obviously there's going to be, I'm going to have a lot more interference and distress every time I think about public speaking. 
So it's my relationship to the sensations; in fact, that kind of can impact how strongly this is a problem or not a problem. So, what is interoceptive exposure? So, we've talked about how fear of the physical sensation can be problematic. So, interoceptive exposure basically uses the concept of exposure but focuses on the bodily sensations, the feared bodily sensations that one has. So, the aim of regular exposure is situational exposure. If I were afraid of dogs, I'm going to hang out with dogs, right? I mean, that's going to be part of my treatment. If I'm afraid of heights, I'm going to have to go to high places. So if I'm afraid of bodily sensations, if I'm afraid of my heart racing or running out of air, then I'm going to actually have to experience those sensations through exposure, right? 

So the goal of interoceptive exposure is then to elicit the feared bodily sensations, to activate any unhelpful beliefs your patient might have that's associated with those sensations, like that I'll die or lose control or go crazy, to bring on those sensations without any avoidance, right? I'm not trying to control them or make them go away. And then essentially, as is the case with all exposure, to allow new learning to take place, to have a new thought and experience related to these bodily sensations, which is essentially that these sensations might be uncomfortable but not dangerous. I realize we didn't say anything about questions. So if you have questions during the presentation, please send them to Mike Christensen in the chat box. 

So don't send your questions my way because I'm not able to read the questions while also presenting. And don't raise your mechanical hand either because we won't be responding to you. Thank you. So just send your questions to Mike. And then, when I stop, I'll take questions. Thanks so much. So then, the goal of interoceptive exposure is to break the link between those physical sensations that one is experiencing when they're anxious and fearful, to break the link between sensations and fear. So you can be like me, you can have sensations, but not actually be afraid of them, right? So you can experience sensations without that anxious fear response to the sensations themselves. Once that happens, the patient will no longer be afraid of being anxious, which is half the battle. With panic disorder, it's pretty much the whole battle or most of the battle. And with other anxiety disorders, it's kind of a piece of the puzzle. It's a tool that you can have in your toolbox. So this is not a treatment in and of itself, right? It's just a method that you can use for patients who struggle with anxiety. So if we can help our patients to not fear those sensations when they come up, then at least we can work with them with cognitive therapy or other kinds of exposure to address other aspects of their anxiety. We can kind of strip away that part of the onion, the part that's related to that fear of physical sensations. 

Now, if you're wondering, like, how can I possibly help my patient not to be afraid? How is it that a racing heart would not be scary or that trembling or shaking or even dizziness or breathlessness would not be scary? Well, I'd like to suggest that you realize that there are things we do Every single day, there are things people choose to do and even pay good money to do that bring on these same physical sensations. So if you exercise, if you lift weights, you're experiencing, you know, if you lift weights, you're feeling some pain, some soreness during, after the next day. And you're willing to experience that discomfort, right? It's for the benefit of getting stronger, right? People pay money to go to amusement parks where they're scared, right? 

Where they experience a racing heart or dizziness or things like that, people actually do drugs, if you think about it, to feel a range of physical sensations, skydiving, and things like that. So I put this slide up so you can see that physical sensations don't have to be scary, right? And even for your patients, they may not be scary in all contexts. And so we want to kind of capitalize on this idea of physical sensations, heart racing, difficulty breathing, trembling, and shaking. We want that mantra. Like, I really want the mantra uncomfortable, maybe. In these cases, they're not even uncomfortable, but they could be uncomfortable, but not dangerous, right? If I spin, I don't really love the feeling of spinning. 

I might even feel nauseous. It's uncomfortable, but it doesn't have to scare me. I don't have to believe that it's dangerous or that I need to avoid it. Um, so then how does interoceptive exposure lead to change? It's essentially the same way that all exposure leads to change. There are different hypotheses about this, and there are data supporting different hypotheses as well. But one possibility, just again, is to think of it the same as all exposure is habituation, right? If we do the same thing over and over again, physiologically, our body habituates or gets used to that experience. Another idea is kind of a more cognitive concept, which is that I learn by doing by facing my fear, you know, by doing jumping jacks, and I'll show you a list of all the different things you can do. 

But by facing my fear by kind of this bring it on mentality about my sensations, I actually discover that none of the things I'm most afraid of actually happen. So, I have learned new things. I realized I didn't actually have a heart attack, even though my race, my heart was racing so fast. I don't lose control even though I feel like I might. So, we can go against the concept of emotional reasoning and learn something really new about my relationship to those sensations and my safety. And to sort of combine the two, you can think of exposure as a set of behavioural experiments. So I'm gonna actually do an experiment to test out the idea that if I were to have a really fast racing heart, I would die, or if I were to feel really dizzy, I would pass out. So you can have a prediction, and then you can do the exposure both for the purpose of habituation and new learning and to kind of contradict that prediction to gather new data or new evidence. Now you might be wondering if you've never heard of interoceptive exposure, what is she even talking about? Like, what are we gonna do to bring on those physical sensations? That part is actually easy. And it's not limited to this list. But here are some of the things I do the most frequently. So, this is the kind of top five that I end up doing with my patients. So jumping jacks is a great exercise you can do for someone who's worried about their racing heart. 

People who have panic disorder oftentimes start avoiding exercise, even though exercise is one of the best things you could possibly be doing for yourself. And their cardiologist will tell them the same. Nothing's wrong with your heart. You know, you should be exercising. So jumping jacks is something we can do, as well as other kinds of high knees, things like that. Burpees are a really high-impact kind of cardio exercise that you can do to get your heart racing. People who are worried about running out of air can practice holding their breath, which can cause some anxiety or mimic some of those sensations. One I like for people who have a lot of worry about suffocating is breathing through a really skinny straw, like a coffee stirrer. 

So we, you know, they used to be able to get those easily at Starbucks, but now they have the nice wooden, you know, coffee stirrers. I buy a box of them from Amazon, but the skinny, like really skinny red or white coffee stirrers, practice holding their nose and breathing through a thin coffee stirrer straw to mimic, you know, feeling like you don't have enough air. For people who worry a lot about dizziness, we can spin. We can stand up and spin and then have a seat, or we can even spin in an office chair, you know, that rotates. And the one that I'm going to do with you guys today, if you choose to opt in, is hyperventilation. And this is my favourite because it actually most reliably brings on a lot of uncomfortable sensations. 

And to be frank, I don't even like doing it; it; I do it with every patient, but I don't even like doing it. It makes me lightheaded. It gives me some, you know, spotty vision and things like that, but it's not dangerous. And you can do it for a short period of time. And it brings on a lot of the sensations that patients with panic disorder, in particular, have a lot of fear about. So, there's a very specific way you do it. So I'm not just telling all my patients to do jumping jacks and hyperventilate. So I'm going to teach you kind of how you do interoceptive exposure with your patients. So there's at least kind of, or there's, two basic phases of interoceptive exposure. 
So,, phase one is what we call symptom induction. This is a kind of data collection. In other words, I'm going to try a couple of different exercises with my patient to see which ones bring on the sensations that are most like their kind of feared sensations. In other words, if you have a patient who already tells you, and it scares me so much when my heart races, well, I'm in my mind thinking, oh, probably what I'm going to try with them is jumping jacks. I'm currently seeing a patient whose core fear and who really came to me saying that she has a problem with dissociation, with feeling these out-of-body experiences all the time. And no one had correctly diagnosed her actually as just having panic disorder. 

She thought she had some a lifelong terrible situation where she would constantly be having these out-of-body experiences. So basically I'm thinking in my mind, oh, hyperventilation is gonna very effectively target what she's afraid of. So symptom induction is what you think of as data collection. We're going to do a couple of different exercises with our patient for a little bit of time, as long as it takes to just bring on some sensations, and we're going to collect data, and I'll tell you what kind of data you'll collect. Phase two is when you are actually going to do the exposure. So the difference between symptom induction and exposure is when we do exposure, we're going to do it intentionally and repeatedly for the purpose of, you know, leaning into their symptoms, bringing them on and again, collecting data, but we're going to do it over time repeatedly with the goal of habituation and new learning. So, let's talk a little bit about symptom induction, right? That's the first phase. So this is just where I first talked to my patient about kind of the rationale for interoceptive exposure and which is essentially that I tell them that, you know, such a part of what's going on for them is this fear of the physical sensations. I tell them what I told you, which is just like if you're afraid of dogs, one of the things we'd need to do would be to hang out with dogs and get you to get you over that fear. 

What we're going to do is kind of hang out with some of these physical sensations. We're going to intentionally bring them on so that you can get really used to them so that you can break the link between these sensations and your experience of fear. And so then I'm going to ask them if they're willing to practice a couple of different exercises with me in order to figure out which exercises bring on the sensations that are most like the ones that they're afraid of. And I say, if we're lucky, these exercises will be scary to you, right? If these exercises are not at all hard for you or scary, then interoceptive exposure is not going to be especially helpful to you, right? If we can hit on an exercise or two that feels scary you know, anxiety producing for you. Well, then we know what we're going to need to repeat in order to get you over this fear. So in this symptom induction, I'm going to invite my patient to do a couple of different exercises, one at a time. And the length of time, I might suggest the length of time, like let's try it for about 30 seconds. But essentially, you can just tell me when you're starting to feel some strong sensations and we'll stop. And then I'll record and you can see here my little table here, then I'll record what you did, right? jumping jacks or hyperventilation, how long you did it for, 30 seconds, 20 seconds, whatever, what sensations you felt. So that might be racing heart or trembling or dizziness, how strong you felt those sensations. 

That would be like zero to 10 or zero to 100, whatever scale you want to use. And then, and this is important, so far we've just been interested in the sensations and how strong they are. But then what I want to know is how anxious they're feeling in that very moment. Because just so you can imagine, the goal of repetition, the goal of this kind of exposure is not to decrease the sensations over time. Every time I spin, I'm going to feel dizzy. I'm never going to expect to be able to spin and not feel dizzy. But what I'm looking for change in is that anxiety rating. I'm looking to see that over time, And it might take a week of daily practice. 

It might take two weeks. But over time, I'm no longer going to be frightened by those sensations. And that's super important for your patient to understand that the goal is not to be able to do this and not feel sensations. The goal is to feel sensations and no longer be frightened by them. And once we get there, you know, then you can imagine that in your life, when you feel these sensations, you'll no longer be frightened by them either. And wouldn't that be amazing? The goal of the symptom induction is to determine which exercises are the most distressing, right? Which ones produce the most anxiety? Because those are going to be the ones that we want to repeat. If a patient does jumping jacks and is not at all frightened, even if their heart's racing, that's fine, but that's not going to help reduce their anxiety, right? 

So we don't need to keep doing that one. We need to do the exercises that are actually causing the anxiety. And then in phase two... We're going to pick one of those exercises. I usually just pick the one that I think is most similar to their naturally occurring kind of panic attacks or anxiety. But you can pick one that's in the middle of their list if they have kind of a range of anxiety. And then the goal is to repeat that one for the same length of time that they did when they practiced it. So if they were able to do it for 20 seconds and that brought on some strong sensations, 20 seconds is all they need to do. each time they practice the exposure. 

So whereas when you do the first phase, I don't need to set a time. It's just however long it takes to bring on sensations. When I do exposure, I actually like to have a set length of time. They're going to do it the same time each time. And the reason for that is that way they're not like escaping or avoiding. They're not each time telling me, oh, I can stop now, right? We're going to set a certain length of time. We're going to each time hit that length. And then we're going to see over time if their anxiety drops. and also when we do exposure, we can ask them, and what, what did you learn, right? We're looking for like, well, it was really kind of scary, but nothing terrible happened, or it wasn't as bad as i thought it would be. 

So we're gonna we can ask them, you know, we're gonna do the same table of the exercise, the sensations, the intensity of the sensations, the anxiety or distress. And then we can also ask, what did you learn? What are you thinking right now? Um, So those are kind of the two phases of doing interoceptive exposure. And what I'd like to do with you guys now, and again, I'll make clear, when I treat patients with panic disorder, I'm always doing an initial screen for any kind of medical problems, right? Almost every patient who comes to see you for panic disorder or most anxiety disorders, if they have this kind of fear, fear has already been to the ER, to their PCP, maybe seen a cardiologist. 

So most of the time they come in totally assured and they can assure you that they have no medical problems and they've been told it's anxiety. If for any reason you're concerned that the symptoms the patient's having could be medical or for some reason that you think doing these exercises is counter-indicated, you're always welcome to check with their doctor, get a release of info, et cetera. But the exercises we're doing, none of them are unsafe for the average person. But I'll say the same thing to all of you. I would love you to do the exercise with me today so that you can see what it feels like and what it's like to walk through it. But if for any reason you don't want to do it or don't think you should be doing it, feel free to opt out. 

So what we're going to do now, I'm going to do the hyperventilation exercise with you. And I'm going to show you kind of how it works. And actually, I'm thinking I'm going to ask you guys to afterwards or to right away to send and tell me, should they send it to me so that you don't get them mixed in with questions? OK, so here's where you're allowed to use your chat box and chat me. So when you're doing the exercise, I'm going to get you started in a minute and encourage you to do it. I'll set a timer and I'll stop at one minute. So we're going to do hyperventilation. I will do it probably for the first 10 seconds. Every person has a different time at which they start to feel really strong sensations. 

And it turns out it has nothing to do with fitness. But like if I do hyperventilation for 10 seconds, I already feel very lightheaded. I start to get tunnel vision. I've done it with some patients who don't feel those sensations for 30 seconds or 40 seconds. So I'm letting you determine how long you're going to do it for. But I encourage you to do it until you feel sensations. And then send a note to me in the chat box. And it just should say... what sensations you feel, like lightheaded six, like meaning zero to 10, and then also your anxiety rating. So what I would love to see is that you're sending me in the chat box what sensations you felt, how strongly, and also how anxious you're feeling when you do it. 

Again, optional. So here's the exercise. Here's what we're gonna do. This is what it looks like when you hyperventilate. So don't start yet. But what you're going to do when I ask you to start is really just breathe like this, like. So it's rapid or sort of deep inhale, deep exhale and do it pretty rapidly. So I'm going to start my timer and I'm going to set it for 60 seconds, but you can do it for shorter or longer. So we'll start together now. It goes like this. And I'm going to encourage you guys to keep going. And then to send me a chat in the chat box, I'm going to open my chat. And just send me when you're done, not during, but as soon as you decide to stop, you're going to send me a chat that just says the sensations you felt and how strong from zero to 10 and how anxious. 

If you're not feeling sensations, just make sure you're doing a very forceful inhalation, exhalation. And we have 10 more seconds if you want to go for a full minute. But again, no pressure. Many of you have stopped by now. And then I'll just have you stop now. So we're at a minute. So I'll have you stop now. And then I'm just going to read some of what I see in the chat box. So let's see. Okay. So I'm getting, and when people said I couldn't finish, remember there was no finish. I stopped after 10 seconds. So all your goal was only to do it until you felt sensations. So dizziness, lightheadedness of an eight, buzzy head of a six or a seven, anxiety of a two, dizziness, lightheaded spinning of a seven, right? 

So we got lots of the Lightheaded dizzy. So you can see this is a pretty effective exercise. This is why I always do this one. It really does bring on some physical sensations. Some people had anxiety of a zero, right? So they're like, I feel totally fine feeling dizzy. Some anxiety of a one. Some had anxiety up to I see a six. I see some people saying they had to stop. Remember, it was totally okay to stop. No one told you you should go the whole time. Some people felt hot, warm, exactly. So stronger heartbeat, sweaty, perfect. Blurry vision, exactly. So again, lots and lots of sensations. Some people, a tingly, nauseous, yeah. All of the above. And I got some people anxiety of an eight up to a 10, et cetera. 

So there might've been a couple people, I'm gonna stop reading them now. You get the gist, right? So there might've been a couple people who didn't feel any sensations. I didn't see any of that. I saw everybody having sensations. If you didn't feel any sensations, sometimes doing it faster works better. For me in particular, actually slower but forceful works. But for some people like... almost like Lamaze breathing, someone said, that kind of thing is helpful. So you can try different things. There's no right or wrong. And then I do want you to remember, because so many of you wrote, I had to stop. I do want you to remember when you're doing symptom induction, kind of phase one, you're not setting a specific length of time. 

So it's stop whenever you feel strong sensations, but then importantly, record the sensations, the intensity, the anxiety rating. So- You know, what I hope that you learn from doing that exercise is that you can do it and you can feel strong sensations. Also, I'm guessing all of you, those sensations have passed by now, right? So you see that even when you do an exercise and you feel probably pretty strong sensations within just, I don't know, a minute, usually those sensations pass. So what I do for patients when I do interoceptive exposure is, I just want to make sure, hold on that eye. Okay, when I do interoceptive exposure with my patients is I have them do it for 30 seconds or however long it takes for them to get the sensations and then kind of let their sensations come down. 
I'll ask them how strong are your sensations now, once they come down to maybe a two or a three, and this is during the exposure phase, then I'll have them practice it again. And I tend to have them practice it three times in a row. I think I have a slide coming up on this, actually, about homework. But I have them practice it three times in a row. There's no magic to that. There may be different people who train you to do it differently. The reason is just that I want them to do it several times in a row. But I also find, unlike a fear of heights or fear of dogs, where you just hang out until your sensations come down, With interoceptive exposure, usually each time you practice it, the sensations get stronger, actually, like each time you practice it in a row. 

And so I'm not trying to get them to get, you know, stronger and stronger. I say three times in a row. It's that I think really the active ingredient is the willingness, like I'm willing to do it again. And the more that they're just like willing to do it, I see the less afraid they are. So I tend to assign that to them for homework three times in a row, the exact allotted amount of time filling out that chart. every single day. And you can imagine it's at the maximum, it's a 15-minute homework exercise, right? It's really less than that, but if they want to take a little time kind of in between each round. I put this slide in here to remember that you can combine interoceptive exposure with situational exposure. 

So for a patient who's afraid of, let's say, you know, going into the grocery store, like that's one of the things that they're fearing. And maybe going to the grocery store isn't that scary for them, but they're like, oh, but if I had a panic attack in the grocery store, that would be really scary. Well, you can have them hyperventilate in the car and then go into the grocery store. You can have them do jumping jacks before going into a meeting. You can encourage the patient to expose themselves, to do interoceptive exposure, sensation-focused exposure to any sensation that they're afraid of. So a lot of patients who have that fear of a racing heart, actually caffeine is the best thing to bring it on. 

A lot of patients who have panic disorder, and I've seen plenty with social anxiety as well, who start avoiding caffeine. And they're like, I love my morning coffee, but I don't drink it anymore because I'm afraid it's going to make my heart race. Well, I know that some people will say, then just stop drinking coffee. But my goal is to have people actually... function exactly like they did before they had the disorder or hopefully even better. So I'd love them to be able to go back to their morning cup of coffee. They don't need to caffeinate all day long. I'm not saying it's great to be jolted all day long, but if you used to enjoy a morning cup of coffee, I want you to enjoy that morning cup of coffee. 

And in fact, if it causes your heart to race, that's awesome because what I really want is for you to practice having your heart race and being okay with it. So I'll even have patient drink a cup of coffee and then come to therapy session with me and then do exercises. I've had patients who have a real fear of getting diarrhea, a real fear of, because when we have physical, you know, when we have anxiety or panic attacks, sometimes your stomach shuts down and you actually do have diarrhea in response to that. And so then those patients, again, they're afraid of having an upset stomach. Well, it's not like I like having an upset stomach, but again, I'm not afraid of having an upset stomach. 

I always share with my patients, and you all might say this is too much information for me to be sharing with you, but I love vegetables. Sometimes I eat too many of them, but I don't really care. So sometimes I eat too much broccoli and cauliflower and cabbage, and I end up feeling kind of sick and having diarrhea, but it doesn't actually stop me from eating them because I'd rather eat my veggies and occasionally have an upset stomach. So you can be the same. You don't have to be afraid of having an upset stomach or afraid of having diarrhea from time to time. So plenty of time I've had patients practice eating two burritos and drinking a beer and seeing what happens. So the goal is, again, we're trying to really help people to not be afraid of the sensations that are getting in the way of them living the life they want to live. 

Doing a plank is another exercise for someone who's afraid of stomach tightness. My point here is just that you can be really creative in applications of interoceptive exposure. I'm actually going to skip this slide so that I make sure that we have enough time. But what I want you to do then is just be thinking of, meaning I'm going to skip having you send your ideas to me. But what I want you to do is think about patients that you're seeing right now and how you might be able to creatively use some exercises to have them face rather than avoid the things that they're afraid of, and in particular, the sensations that they're afraid of, right? So again, we can empathize with the fact that no one loves having an upset stomach or a headache or feeling dizzy, but at the same time, we don't have to lead our lives afraid of these. 

And then we can design exercises with our patients to face those fears. And again, there's a whole list of interceptive exercises that people frequently use, but I just want you to feel the creative license to kind of think with your patient about what they could do to face some of the sensations that are making them feel afraid. So let's talk a little bit. I'm going to kind of shift gears from interoceptive exposure to thinking about safety behavior. So today's presentation is kind of how to use interoceptive exposure, and then how to think about safety behaviors, because these are two really important aspects of treating anxiety disorders successfully. So the definition of a safety behavior, then, if you're wondering what that is, if that's not common kind of language for you, is it's a behavior, any behavior that's performed by someone who's anxious in an attempt to minimize or prevent 
a feared catastrophe, right? So it's something you do when you feel anxious to try to help yourself feel less anxious and try to make sure that nothing terrible happens. So here are some examples of common safety behaviors.

So sitting near an exit is a safety behavior for someone who's, let's say, has panic disorder or even social anxiety. And they think, oh, if I sit near the exit, then I can get out. I can escape really easily. So that means they're strategizing in business meetings, in movie theaters, on the airplane, right? I mean, I wasn't even thinking airplane exits, but easy exit to the bathroom, things like that, right? So having someone accompany you saying, well, I could do it, but I would need to make sure someone was with me. 

Many times people with anxiety disorders start to get really dependent on people in their lives to be with them, to accompany them doing things that are scary. And again, so long as we have someone accompanying us, we're not actually really facing our fear, right? This makes us feel more comfortable and less afraid that something terrible would happen. Sometimes for people who are afraid their heart's going to start beating, they'll want to walk really slowly. They'll want to make sure they carry a water bottle in case their mouth gets dry, a cell phone so they can get help. holding onto something for support. I can give you, I'll give you a story about that, I think in a later slide about a patient who did that. 

Staying cool. So some patients, I mean, lots of patients will tell you, oh, if I'm driving in the car and I get anxious and pinnacle, I turn the air conditioning on, like that helps me to feel better and calmer and kind of more in control, then my anxiety won't really escalate. Lots of people use alcohol or benzodiazepines as safety behaviors, right? They're like, well, I can go to that social function as long as I have a drink before, or as long as I have a drink in my hand, or as long as I take my benzodiazepine, or as long as I carry it with me, right? I don't even have to take it. I just have to know it's with me. So there are many other safety behaviors that people engage in. 

And the more you get to know your patients and you ask them, you know, tell me, like we talk about the function of safety behaviors, and then we ask them, What do you think you might be engaging in that's helping you to feel safer in that situation? The more that you're going to learn about their unique safety behaviors. Seeking reassurance, of course, is a really common safety behavior too. Verbal safety behaviors would be saying sort of self-assuring statements or mantras, right? So If one is saying you're okay, you're okay, you're okay, or you're safe, you're safe, you're safe, things that people need to say, or even some sort of little prayer or something like that. Now, I want to be clear, I'm not anti-prayer, right? 

And I'm not anti-meditation. If one does something like this once a day, it's not been a safety behavior, right? Like if this is part of your daily practice, meditation or prayer, but if you start to feel like I need to do it, I need to do it repeatedly, I need to do it to help myself to feel better in the moment, then it's something that you're leaning on repeatedly to try to control your anxiety. It becomes a safety behavior. And why is a safety behavior a problem? You all might be thinking like, I don't know what you're talking about, Jill. These are coping strategies, right? Like why are these a bad thing? So this is a good question. Like why is having someone with me or making sure I have my phone or my meds or my water bottle 

Why is it a problem? And the problem with relying on safety behaviors is that you can still essentially face your fears. You can still do exposure, but the exposure is not going to be nearly as effective, right? Because you might sort of white knuckle it or feel okay in the moment, but in the long run, you're not actually going to think that you're safe, right? I'm only safe if I have someone with me. I'm only safe if I have my medication, which means parentheses, I'm not actually safe, right? The message I'm sending myself is I'm totally still in danger, right? I only feel safe because of A, B, and C, which means this thing is actually still pretty dangerous and scary. So there is research that shows that safety behaviors do interfere in the success of exposure and exposure therapy. 

But I will also tell you in a slide or two about how you can incorporate safety behaviors into exposure hierarchies, right? Because I'm not at the same time trying to strip everyone away, strip everything away from every patient immediately and just, you know, throw them to the sharks. So we'll talk about that in a minute, but think about the problem with safety behaviors, because most of you are going to be like, you know, safety behaviors are good and my patients can hold on to their coping strategy. So I encourage you to think more about, kind of this side of things, which is that you're not really fully confronting your fears if you're using safety behaviors, because you're still really trying to control your anxiety. 

You're not like, bring it on, show me what you got, I'm good. You're like, I'm good only if, and I control it in this way and that way, and these are the conditions under which I'm going to be okay. So you want to ask yourself, is this behavior ultimately helping this patient in the long run? And I put this example of patient at Costco on this slide because I think it's sort of a fun, sneaky one where I had a patient who had panic disorder and one of the triggers for him was going to Costco because it's big and the ceilings are tall and it can be really crowded. So I do outside of session, outside of office practice with my patients. And I said that we were going to meet at Costco and we would do an exposure at Costco. 

And so- We got there and we go inside and he's like, OK, I'm just going to grab a cart. And then I started chuckling and I was like, oh, but, you know, we're not shopping, right? Like we're just doing exposure, even though I secretly wished we could go shopping while on the clock. But I said, oh, you don't need a cart, you know, because we're just going to do exposure. We're going to go walk around and we're going to stand in the areas of the store that are hardest for you. And he's like, oh, no, I need a cart because it's going to keep me stable, you know, because that way, if I'm kind of woozy or, you know, feel dizzy, like the cart will stabilize me. 
So of course, I'm going, Oh, wow, the cart is a safety behavior. He's thinking I'm only safe if I'm holding on to this heavy shopping cart. And so of course, I shared that with him. And we talked about it, we had already talked about safety behaviors. So we ended up deciding based on his sort of willingness and anxiety that I would we would do exposure first using the cart. And then we would drop that drop the safety behavior. So I That kind of brings us to the idea that you can include safety behaviors in your sort of hierarchy, but you also need to know that ultimately the goal is to drop those safety behaviors out, right? Anxiety is going to be highest when doing exposure without safety behaviors. 

And lots of people will say, you know, throw you in with the sharks and do it without safety But I also know there are lots of therapists, myself included, some of the time who feel like I'm going to meet the patient where they're at. And I know I can get this patient where they need to go, but I need to let them take their time. And so in that case, you can think of using safety behaviors as ways of facing fears in a way that's not a 10 out of 10, but maybe it's a five or a six. And then they're going to do it the next time or the next week without the safety behaviors. That's kind of the goal. So you want to think with yourself and you want to think with your patient about the costs and the benefits of using safety behaviors, right? 

In the short term, the patient is going to feel better and it's going to feel easier. And they may be more likely to engage in exposure and that may be helpful. But in the long term, if they're engaged in lots of safety behaviors and they're still have mantras and meds and water, then they're really not doing exposure and they're not getting a full cure by any means if they're holding onto all of these coping strategies. Because our goal is to get them to see that there is nothing to be afraid of, right? That they can wholeheartedly engage in all the things that are important to them in their life and feel anxiety even, but that then nothing catastrophic happens And with repeated practice, that anxiety will drop, right? 

When they keep discovering that they can do it and that it's less scary than they thought and that those sensations pass, then they're gonna get where we want them to go. And that's gonna happen a lot more completely if we can get rid of all of their safety behaviors. So kind of my final thoughts here then with when I work with patients with anxiety disorders, is that I want them to really lean in to all sensations. All the sensations are safe sensations. And so I don't want them to be in the position of avoiding their sensations. And I listen really carefully to the stories my patients tell, to the homework assignments they complete, to discover, you know, to be on the lookout for times where they're like, oh, and then I decided to drive this way instead of that way because it seemed easier, you know, or I, you know, this worked, but only because I had the air conditioning on and I called my mom and that was really nice and distracting, right? Like I'm paying attention to that. I'm educating them about that. And then I'm encouraging them with my support and with practice to kind of drop all of that avoidance, including avoidance of physical sensations. So I hope that it kind of adds to your arsenal where you can think of interoceptive exposure as a way to help your patients, and yourself too, right? Because lots of therapists have some of these fears too, to overcome a fear of physical sensations. With repeated practice, and maybe you need to practice this on your own, and you definitely need to practice with your patients, I want you to not be afraid to make your patients anxious, right? 

That is actually the whole point. People ask me about what I like about doing therapy, and I say, the thing that I love about treating anxious patients is they don't make me anxious. So I could be working with a very depressed patient. And over time, I mean, I can see the distortions, but sometimes I can feel pretty sad for them too. Oftentimes they have pretty sad things going on in their life. But anxiety, to me, is mostly extremely distorted. And so kind of if you can help yourself not to buy into the fact that these sensations are actually bad and that these situations are actually dangerous, you're going to help your patients. So I hope you will... use interoceptive exposure to disprove your patient's anxious expectations, to help them build grit, to help them be hearty in the face of physical sensations, and also to be really creative, you and your patients, in your application of interoceptive exposure. 

So now my goal is to turn to Mike and to take a couple of questions, and then I need to leave a few minutes for some wrap-up slides at the end too.

Q n A Session

Mike: Um, the last question, which I think is going to lead to some of the things you're talking about next, is what the resources are. Is there other trainings that you have available that people can, can get more?

Jill: Sure. So, number one, the slides that I offer today, which definitely have some templates for doing interoceptive exposure, are in the files menu on the course page. We do offer lots of other training, and I'll share that with you. Then, I have a resource slide with some references.

And I will say that there's one, Mike. Maybe you can just put it in the chat box, but there is a workbook that's called Mastery of Your Anxiety and Panic that is by Barlow, David Barlow and Michelle Krask. And that is, those are the people who actually originally kind of designed and discovered interoceptive exposure, you know, like more than 20 years ago. So that's a good reference. But I will also tell you that if you're interested in doing more training with us, I'm doing an intensive with Dr David Burns. David used to do these intensive therapist training, four-day training in South San Francisco for years and years prior to COVID and then hasn't done one since 2019. And as many of you know, David is 82. And so many of us are really jumping at the bit to see him in action. 

So, I'll be teaching alongside David at a three-and-a-half-day workshop called Advanced CBT for Depression and Anxiety. And we will cover a lot about doing exposure. It's in person in South San Francisco and also live-streamed online. There's more info about it on our website, but the quickest link is So you can find out more about it. Also, we typically offer these webinars monthly. Next month, the first Wednesday of the month is the week of July 4th. Instead, we're going to do the next webinar on June 26th. That's going to be offered by Kevin Cornelius with Feeling Good Institute, which is talking about incorporating intensive one-on-one therapy sessions into your practice. So, I am kind of teaching you some tools, tidbits, and gems about how to do longer sessions and more intensive therapy. 

So, This one is an intensive workshop for therapists, right? Then, actually, the webinar talks more about how to do intensive therapy with your patients. So that's on June 26th at noon, and that's a free one-hour, one CE webinar. Mike also dropped the CE survey into the chat box. So make sure that you complete that CE survey. And I think... Yeah, I thought it was in the slide deck, but the references are on the course page. So they're not in the slide deck, but they're definitely on the course page if you want to find more references. And we're just at the one o'clock mark. So, I'm going to say thank you so much to everyone for attending this webinar. We love offering training to our community, connecting with you, and trying to answer your questions and help you become a better therapist. We also love referrals. If you have patients that you think would benefit from seeing one of us at Feeling Good Institute, so you can see our website at feelinggoodinstitute.comIfif you have any questions about our traini,or CE certificati,on or anything like that, reach out to certification at

Mike: Thanks so much, Jill.

Jill: Thank you, Mike. And thanks, everybody else. Hopefully, we'll see you at the intensive or next month. Take care. 

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